A nurse is caring for a patient who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment which correlates with a fluid volume deficit? (Select all that apply)

Choice A reason: Urinary status, such as output, monitors hydration and kidney function post-surgery but is unrelated to safe oral intake. Abdominal surgery risks paralytic ileus, where intestinal motility ceases, increasing aspiration risk if food is consumed. Bowel sounds indicate gastrointestinal function recovery, making urinary status a secondary consideration for dietary decisions.

Choice B reason: Skin turgor assesses hydration but does not determine readiness for oral intake post-surgery. Abdominal surgery can impair peristalsis, causing ileus, which risks vomiting or obstruction if food is introduced prematurely. Assessing bowel sounds confirms intestinal motility, critical for safe eating, while skin turgor is irrelevant to gastrointestinal recovery.

Choice C reason: Pain level is important for patient comfort but not the primary consideration for eating post-surgery. Pain may indicate complications, but absent bowel sounds suggest ileus, a condition where the gut lacks motility, risking aspiration. Bowel sounds confirm peristalsis, ensuring safe digestion, making pain a secondary factor in this context.

Choice D reason: Bowel sounds indicate gastrointestinal motility, critical after abdominal surgery to prevent complications like ileus. Absent sounds suggest impaired peristalsis, increasing risks of vomiting or obstruction if food is consumed. Auscultating active bowel sounds confirms the gut’s readiness to process food, making this the primary consideration before allowing eating to ensure safety.

Choice A reason: Nonmaleficence, “do no harm,” is exemplified by protecting clients from an impaired provider, whose opioid use could lead to errors or unsafe care. This action prevents harm, prioritizing patient safety, and aligns with ethical principles of nursing, per professional standards and patient advocacy.

Choice B reason: Performing dressing changes promotes healing, an act of beneficence (doing good), not nonmaleficence. While it prevents infection, the primary intent is therapeutic benefit, not harm prevention, making it less aligned with nonmaleficence’s focus on avoiding harm, per nursing ethics.

Choice C reason: Providing emotional support is beneficence, as it actively benefits the client’s well-being. Nonmaleficence focuses on preventing harm, not promoting positive outcomes. Support reduces anxiety but does not directly address harm avoidance, making it incorrect for nonmaleficence, per ethical principles in nursing.

Choice D reason: Administering pain medication is beneficence, relieving suffering to improve comfort. Nonmaleficence involves avoiding harm, not providing therapeutic relief. While safe administration prevents harm, the primary goal is pain relief, not harm prevention, per nursing ethics and pharmacological care principles.